Three years ago, the World Health Organization declared that the mushrooming outbreak of a new coronavirus — later named SARS-CoV-2, the cause of Covid-19 — posed such a threat to global health that it merited designation as a public health emergency of international concern.
On Friday, an emergency committee will meet again to deliberate whether the time has come to recommend to WHO Director-General Tedros Adhanom Ghebreyesus that he declare the global health emergency is over. The final decision rests with Tedros, who generally — though not always — follows the advice of WHO emergency committees.
This gathering, the committee’s 14th, comes as Covid rips for the first time through the world’s most populous nation, after China lifted the draconian “zero Covid” policy that kept the virus at bay for nearly three years. That factor alone could persuade the committee that this is not the time to advise Tedros to call an end to the PHEIC, a designation that grants the WHO director-general certain powers, including the ability to issue recommendations for how countries should respond.
On Tuesday Tedros hinted he doesn’t feel the time is right, noting that Covid deaths are on the rise again globally. Over the past eight weeks, more than 170,000 such deaths have been reported, he said, adding that figure is certainly an underestimate.
“While I will not preempt the advice of the emergency committee, I remain very concerned by the situation in many countries and the rising number of deaths,” the director-general said during the WHO’s weekly press briefing. “While we’re clearly in better shape than three years ago when this pandemic first hit, the global collective response is once again under strain.”
Whatever the decision Friday — which likely won’t be revealed until Monday — outside experts acknowledge the Covid pandemic may no longer strictly meet the criteria for a PHEIC (pronounced “fake”).
Under the International Health Regulations (IHR), a binding international treaty, a public health emergency of international concern can be declared in the face of a health event that meets three criteria: it is serious, sudden, unusual, or unexpected; it has the potential to spread across borders; and it may require a coordinated international response.
Covid is still serious, but sudden, unusual, or unexpected? Not any more. Borders have been crossed; the virus has spread planet-wide. At this point in the pandemic, international responses are being wound down.
Still, Tom Bollyky, director of the global health program at the Council on Foreign Relations, doesn’t expect quick action on terminating the PHEIC. He suspects the WHO may end the Covid PHEIC in 2023 — but not now.
“I think they will be particularly slow here, given a still quite high death toll, given what’s happening in China,” Bollyky said, noting that in the past, the WHO hasn’t been quick to end PHEICs.
The emergency committee itself has indicated, though, that it is thinking about how to land the plane. The committee has met a dozen times since the Covid-19 PHEIC was declared on Jan. 30, 2020; the reports of 11 of those meetings stressed there was unanimous agreement among committee members of the ongoing need for a PHEIC. In the report of its most recent meeting in October, there was no mention of “unanimous” agreement that the pandemic still constituted a PHEIC.
At the October meeting, the expert panel asked the WHO staffers who assist it to set up a session at which it could discuss how a PHEIC could be terminated safely. In particular, it asked for advice on potential negative consequences of ending the PHEIC, and whether WHO could still issue temporary recommendations to countries on how to respond to Covid once the PHEIC was over. The IHR gives WHO the power to issue temporary recommendations to countries while a PHEIC is underway, for example, recommending countries not put cross-border travel restrictions in place. In theory those recommendations are binding, but in reality the treaty has no enforcement mechanism and countries can and do ignore the recommendations, as the United States did recently when it instituted a requirement that travelers from China produce a negative Covid test to enter the country.
The discussion on how to safely end a PHEIC will take place Friday, in conjunction with the meeting of the emergency committee, WHO spokesperson Tarik Jašarević told STAT. “It is an informal technical discussion of the committee with the secretariat on the criteria for terminating the PHEIC.”
One of the problems for this committee, and for the WHO, is that while there are guidelines for when a PHEIC may be declared, there are none for when one should be ended.
“There is certainly no defined pathway for when a PHEIC is no more a PHEIC,” said Preben Aavitsland, state epidemiologist at the Norwegian Institute of Public Health.
Since the tool was created, seven PHEICs have been declared: for the H1N1 flu pandemic in 2009; the large West African and North Kivu Ebola outbreaks; the Zika outbreak; the international mpox outbreak; and the Covid pandemic. In 2014, when rising case counts appeared to threaten the decades-old effort to eradicate polio, a PHEIC was declared for polio, which remains in place to this day.
Most of the earlier PHEICs were called in response to disease events where transmission was eventually stopped, making it easier to know when to declare an ending, Aavitsland said. (Even though the 2009 flu pandemic virus did not disappear, it settled into a seasonal circulation pattern within about 15 months of its initial detection. The H1N1 pandemic was declared a PHEIC on April 25, 2009; the PHEIC was ended on Aug. 10, 2010.)
The Covid situation is markedly different, with the virus still causing high numbers of deaths — averaging about 600 a day in the U.S. alone at this point. The rapid-fire evolution of the virus, with a succession of variants and subvariants that have eroded the protection against infection created by vaccine-derived and infection-induced immunity, also gives pause to people trying to assess where we stand with this new virus.
“With major Ebola outbreaks it’s easy. The PHEIC ends when the outbreak is over. This outbreak, however, does not disappear. The virus is here to stay,” Aavitsland said.
Still, he believes it is past time to end the Covid PHEIC.
“What will change between now and the next [emergency committee] meeting in April? And the meeting after? Several hundred millions Chinese will be infected for the first time. Several hundred millions Americans, Europeans, Africans, and Asians will be infected for the second or third time. And so on. There’s no need to wait,” Aavitsland said.
David Heymann, a professor of infectious diseases epidemiology at the London School of Hygiene and Tropical Medicine, also believes the need for a PHEIC for Covid may have passed.
Heymann, who spent two decades at the WHO, was the chair of the emergency committee that was set up to advise the global health agency on the Zika outbreak of 2015-2016. That PHEIC is the shortest on record, having been wound down in just under 10 months.
“When we understood that WHO had a control mechanism in place for Zika, and when they had an advisory group that could handle Zika recommendations for them, we felt that the public health emergency of international concern was over,” Heymann said.
Is there any rationale for prolonging the Covid PHEIC? “Based on the criteria that the committee that I chaired used, no,” he said. “I cannot see the reason to continue it.”
Ending the PHEIC would not be a declaration that Covid no longer poses a threat to the world, nor would it constitute a declaration by the WHO that the pandemic is over.
In fact, there is unlikely to be a declaration of the end of the pandemic — not now, not later. The International Health Regulations do not include provisions for a formal declaration of a pandemic and they don’t have a mechanism for declaring that one has ended. Though many experts and news outlets around the world — including STAT — interpreted a March 11, 2020, acknowledgement by Tedros that a pandemic was underway as a formal declaration, in reality the WHO does not declare that a pandemic has started nor does it signal when one has ended, Maria Van Kerkhove, the agency’s leading coronavirus expert, told STAT. “We don’t declare pandemics,” she said.
The PHEIC also does not confer on the WHO powers that are similar to those that the U.S. federal government acquired when it declared the new virus a national public health emergency in January 2020.
(Health and Human Services Secretary Xavier Becerra renewed the public health emergency declaration on Jan. 11, the 13th extension of the provision. It is widely expected the latest extension will be the last, and that Becerra will announce in early February that the federal government will allow the emergency status to lapse on April 11.)
“What the PHEIC is largely meant to do is to prompt and empower nation states to act. It’s meant to raise an alarm, to inspire action,” Bollyky said. “What the public health emergency designation is meant to do in the U.S. is empower the federal government to act. … So they’re just fundamentally different in that regard. Having a PHEIC does not empower WHO to do much.”
Why keep it in place then? “It gives them political coverage that they’re taking this seriously,” he said.
Amanda Glassman, executive vice president of the Center for Global Development, said in her view, the decision of the emergency committee on Friday could go either way. But regardless of what the group decides, she said, one thing has been made clear by the Covid pandemic — the PHEIC mechanism needs an overhaul.
“The whole binary nature of the PHEIC, yes or no, is fundamentally unsuited to the evolution of these diseases and these events,” she said, noting that the tool doesn’t appear to be doing what it was designed to do.
“The PHEIC did not help us coordinate policy,” Glassman said. “I think later, we should reflect on this mechanism, and whether it’s doing what it’s supposed to do in the first place.”
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